Basic Information
| Provider Information | |||||||||
| NPI: | 1760772321 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ALLEN | ||||||||
| FirstName: | JUSTIN | ||||||||
| MiddleName: | MICHAEL | ||||||||
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| Credential: | FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 808 W 58TH ST | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900373632 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 808 W 58TH ST | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900373632 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3235411600 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/15/2011 | ||||||||
| LastUpdateDate: | 08/28/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 95004179 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 163WG0000X | 672425 | CA | N | Nursing Service Providers | Registered Nurse | General Practice |
No ID Information.